Subacromial Decompression in Patients With Shoulder Impingement With an Intact Rotator Cuff: An Expert Consensus Statement Using the Modified Delphi Technique Comparing North American to European Shoulder Surgeons

Purpose: To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences. Methods: Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤60% for an item, the results were carried forward into round 4. For round 4, the panel members outside consensus (>60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%. Results: There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the workup; magnetic resonance imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%). Conclusions: Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures. Level of evidence: Level V, expert opinion.